Unresolved issues

The efficacy of zidovudine in preventing HIV transmission to the child from an HIV positive mother who breastfeeds is currently not known. Zidovudine may provide some degree of protection, although probably less than the protection it provides to infants who are not breastfed. Since the majority of HIV positive women facing transmission from mother to child are women who breastfeed, it is critical to resolve this issue. It is also necessary to learn more about the effect on the morbidity and mortality of infants born to HIV positive women of introducing alternatives to breastfeeding.

Nevertheless, the greatest reduction in mother to child transmission of HIV is likely to occur when an integrated prevention programme is implemented which combines the provision of zidovudine and safe alternatives to breastfeeding. In some countries, it may prove to be impractical to implement simultaneously access to zidovudine and access to safe alternatives to breastfeeding. In these situations, the implementation of one prevention component should not be delayed until the other is feasible. Furthermore, if a woman chooses not to use both zidovudine and safe alternatives to breastfeeding, she should still have access to the intervention of her choice and should be supported to carry out the use of this intervention safely and effectively.

Other unresolved issues involve the efficacy of even shorter regimens of zidovudine than that used in the Thai study, and the efficacy of interventions which do not require knowledge of serostatus, such as Vitamin A supplementation and vaginal cleansing for prevention of mother to child transmission. Results from ongoing research will indicate whether or not these can be proposed as effective interventions on their own, or only as measures complementary to an antiretroviral regimen.

Additional research is also required on issues such as factors influencing the uptake of voluntary testing and counselling, not returning for HIV test results, adherence to the regimen, and acceptance of interventions to prevent mother to child transmission.